Membership Registration Form
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57th Ohio Civil War Round Table - attn: Robert Tong 422 West Sandusky St.
Findlay, Ohio 45840 Name___________________________________________________ Address_________________________________________________ City/State______________________________ Zip____________ Telephone (Home) (____)______________ (Work) (____)________________ (Fax) (____)______________ E-Mail____________________________ Birth date_____________________ Civil War Rank:_____________________ Unit (if affiliated) ____________________________________ U.S.A____ C.S.A_____ Civil War Position: ____ Re-enactor ____Surgeon ____ Asst Surgeon ____ Nurse ___Hospital Steward ___ Collector ___ Historian ___ Lecturer ___ Researcher ___ Civilian ___Other (Specify)___________________________ Primary Civil War Interest___________________________________________________ How did you hear about the 57th Ohio Civil War Round Table ? ______________________ Membership Categories/Annual Dues: Student Individual 12 – 16 Years Old $15.00 Individual Membership $25.00 Family Membership* $50.00 Life Time Membership $250.00 Hancock Historical Museum Member Discount $5.00 * Please list the names of all family members on separate sheet of paper Dues are for a calendar year (January 1st - December 31st) Make check or MO payable in U.S. dollars (we cannot accept checks/MO's drawn on foreign bank due to the exchange rate charges)
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